Patient Information Guide to Bone Fracture,
Bone Reconstruction and Bone Fusion:

                                  Wrist and Hand

The wrist joint is made up of the two bones in your forearm
(the radius and the ulna)  and the many tiny bones in the base
of your hand (carpal bones).

The radius is the bone on the thumb side of the forearm, and the ulna is the outer bone of the forearm located on the side of the little finger. Fractures of these bones in the forearm are the most common wrist fractures in all age groups.

Wrist fractures occur most often in a fall or in a car accident, but any sufficiently strong force on the hand can break the wrist. The wrist can be broken from a sudden force pushing the hand backwards, normally this is a fall on an out  stretched hand.

The most common types of wrist fractures are those involving  one of the wrist bones.

                                       1.                                                                  2.
 

1. A scaphoid fracture, which is a fracture of the schapoid bone. 
2. A Colles fracture("distal radius fracture") is a wrist fracture involving a break of the end of the radius bone of the forearm

The treatment of a wrist fracture varies widely and depends on its location, position, and stability, and how many pieces of broken bone have been created by the injury. Some fractures are unstable enough that a cast cannot hold the pieces of bone in a normal position for healing, and surgery may then be necessary to fix the bone back together. Normally metal or biodegradable pins, plates and screws are used to do this and what is used will depend on the type of fracture the patient has.

Scaphoid Fracture Symptoms 

• Symptoms include pain and tenderness on the thumb side of the wrist

• Pain when gripping an object

• A deep, dull ache in the wrist.

Diagnosis of the problem?

The diagnosis is made first by a hands on examination given by your doctor and then if a wrist fracture is suspected, your doctor will ask you to have an x-ray to determine if the bone is broken. After a fall onto a wrist, it's important to have the wrist examined as soon as possible. Untreated scaphoid fractures often do not heal, which can eventually lead to wrist arthritis.

The following is a general overview of the possible treatment options, your doctor might recommend for you.

Treatment depends on the extent of the injury and may require a cast or surgery. Healing time can range from six weeks to six months, depending where in the bone the break has occurred. A break in the lower portion of the scaphoid takes longer to heal due to poor blood supply.

At its best, this is a slow-healing fracture, requiring an average of 3 months in a cast that extends over the thumb. This fracture may require surgical treatment, such as bone grafting (taking bone from another part of the body normally the hip).

Having surgery to repair the break normally involves using metal or biodegradable screws to hold the bone pieces in place. There are many different types of surgery, and treatment and your doctor will decide on the best one to treat your fracture and ensure that the healing process will go without problem.

Even with immediate attention, not all scaphoid fractures will heal. This nonunion (failure for bone to repair) can be repaired with a surgical bone graft and internal pins or screws.

Incorrect selection, placement, positioning, or fixation of the implant can cause subsequent undesirable results or breakage of implants or instruments. The surgeon should be familiar with the devices, the method of application and the surgical procedure prior to performing the surgery (please see the product-specific instructions for use). The Inion implants are not intended to replace healthy bone or withstand the stress of full load bearing. Always use appropriate additional immobilization (e.g., suitable cast, brace, crutches and/or rigid fixation implants) postoperatively during the healing period and provide the patient with detailed instructions for postoperative care (e.g., regarding immobilization and hygiene maintenance). The patient should be warned that the implants can break or loosen as a result of early stress, activity or load bearing. Premature discontinuation of the cast or other immobilization technique may cause non-union or mal-union of the fracture or osteotomy. 

When someone falls on their outstretched hand for example; a fall when roller blading, they may get a broken wrist. The bone that is usually broken is called the radius. It is the larger bone on the upper side of the X-ray below.  The end toward the wrist is called the distal end.

Distal radius fractures are among the most common bone injuries. When a person lands heavily on an out stretched arm the radius cannot support the weight and breaks just above the wrist joint. A distal radius fracture can also be called a Colles fracture, which is the name of the Irish surgeon Abraham Colles who first discovered this type of fracture.

This fracture is often painful, sending most patients to seek immediate medical attention. It is typically seen in older patients with osteoporotic bone. Soft, osteoporotic bone can make it difficult to treat this break, leading to a malunion (crooked wrist), pain and loss of strength. Some cases, this fracture may be treated with a cast. This procedure may be done in the emergency room or the hand surgery clinic.

• Pain and swelling

• The presence of bruising (black and blue discoloration) is common

• A deformity, causing the wrist to look bent.

• You may have numbness in you hand and fingers, which can mean your blood circulation has been restricted to the area due to the trauma.

The doctor will take an X-ray of the wrist. The fracture is almost  always about1 inch or so from the end of the bone. If the fracture extends into the joint, it is called an intra-articular fracture – if it does not, it is called an
extra-articular fracture. (articular means joint.)

If the fractured bone breaks through the skin, it is called an open fracture. If the bone is broken into more  than two pieces, it is called a comminuted fracture.  A fracture is much more difficult to treat if it is intra-articular,
open or comminuted.

There are many treatment choices. Your orthopaedic surgeon will describe what options are right for you. The choice depends on many factors, such as the nature of your fracture, your age and activity level, and your doctors preferred method of treatment.

One choice is to leave the bone the way it is, if the bone is in a pretty good position. Your doctor may apply a plaster cast until the bone heals. If the position (alignment) of your bone is not good and likely to limit the use of your arm, your doctor may suggest correcting the deformity (the medical term for correcting the deformed bone is reduction). If the doctor can straighten out the bone (reduce) without the need for performing actual surgery then this is called a closed reduction. After the bone is properly aligned, a splint or cast may be placed on your arm.

Treatment Options: Surgical

The following is a general overview of the possible treatment options, your doctor might recommend for you.

If your doctor thinks that the position of the bone is not acceptable for the future function of your arm, and that it cannot be corrected or kept corrected in a cast, he or she may recommend surgery.

By making an incision (open reduction) the doctor has a clear view of the
fracture area and therefore can improve the alignment of the bone.
In the operating room, your doctor may choose to hold the bone in the correct  position with only a cast, or by repairing the fracture with metal or biodegradable  screw and plates as seen on the right.

• Pain

• Swelling

• A palpable deformity

• Difficulty moving the fingers

 Diagnosis of the problem?     

If a fracture is suspected, your doctor will request an x-ray to determine  if the bone is broken. If a fracture is seen in one of the bones of the hand a decision will be made to determine appropriate treatment for the injury

Cast & Splints:
If the fracture is not displaced (meaning it is in proper position) a cast or splint will likely be sufficient for treatment of the fracture. T here are some types of hand fractures that do not necessarily need to be in perfect position in order to heal properly. These fractures may also be cast or splinted and allowed to heal.

Surgical treatment

Pins:                                                               
Small metal or biodegradable pins may be inserted through
the skin in order to hold the bones in a better position.

This procedure is usually done with the patient under general
anesthesia, but may also be done with a local anesthesia block.

The metal pins remain in place for several weeks while the
fracture heals, and then the pins can usually be removed
in the doctor’s office.

Metal or Biodegradable Plates & Screws:                            
In some types of hand fractures more treatment may be
necessary.

In these cases, biodegradable or metal screws with
either a plate or an external fixator (fix’s the bone from out side the skin) can be usedto help maintain proper alignment of the bones.

Every doctor has their own method of managemen of their patient, but generally rehabilitation with physical therapist will be required. If surgery is required the doctor may choose to remove the metal pins or plates once  satisfied that the fracture has mended.

Many of the small joints in the wrist can become arthritic. When this happens, the wrist joint can become extremely painful. Moving your wrist may become difficult because of the pain and stiffness. Your grip can also get weak from the pain. Whenever the hand grips or uses strength in any way, the wrist feels the force. This happens because the muscles running from the forearm to the hand contract, tightening the wrist bones together. This causes pain.

A fusion of any joint eliminates pain by making all the bones grow together into one solid bone. When the bone ends can no longer rub together, there is no more pain. Fusion surgeries are used in many joints.

A wrist fusion is a tradeoff. You will lose some motion, but you will regain a strong and pain-free wrist. Regaining strength is especially important to younger people who need to work with their hands. These patients need strength more than flexibility. Wrist fusion gives them a strong wrist that is good for gripping. Patients who need more movement than strength should consider another type of operation, such as an artificial wrist joint replacement

The following is a general overview of the possible treatment options, your doctor might recommend for you.

Your doctor can fuse wrists in may different ways. In the past, most of the procedures used a bone graft from your pelvis. Doctors now try to take a small amount of bone from the end of the radius bone instead. A bone graft involves taking bone tissue from one area and transplanting it into another area. This encourages the ends of the bone to grow together. If your doctor grafts bone from your pelvis, you will have two incisions--one on the back of your wrist, and another on the side of your hip. Your surgeon may also try to fuse the bones without a graft.

Surgery may be done using a general anesthetic, which puts you to sleep during surgery. In some cases, surgery is done using a local anesthetic, which numbs just the wrist and hand.

The tendons and ligaments are moved to the side. This allows the doctor to see all the bones and joints of the wrist. The articular cartilage is then removed from each joint that will be fused. At this point, the wrist joint consists of many small bones with space between them where the cartilage is missing. If you are getting a bone graft, the graft is then placed between each of the spaces in the wrist bones.

The doctor then places a metal or biodegradable plate with screw holes on the back of the wrist. The plate goes from the radius to the metacarpal bone of the middle finger. The plate is attached to the bone with metal or biodegradable screws as seen in the picture below. The plate keeps the bones from moving so that they stay in proper alignment while they grow together. The plate usually stays inside your hand permanently. It is not removed unless it causes problems.

Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once your surgeon is sure that fusion has occurred, you will begin a strengthening program. It will take some time to regain the strength in your hand and arm. As with any surgery, you need to avoid doing too much, too quickly.

A fusion (also called an arthrodesis) of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Even today, joint fusions are still very commonly used in many different joints for treating the pain and potential deformity of arthritis.

Arthritis of the finger joints may be surgically treated with a fusion procedure. Fusion keeps the problem joints from moving so that pain is eliminated.

Diagnosis of the problem?

The diagnosis is made first by a hands on examination given by your doctor and then your doctor will ask you to have an x-ray to determine that there are no bone fractures.

Treatment?

The following is a general overview of the possible treatment options, your doctor might recommend for you.

Surgery may be done using a general anesthetic, which puts you completely to sleep, or a local anesthetic, which numbs only the hand. With a local anesthetic you may be awake during the surgery, but you won't be able to see the surgery.

An incision is made on the back part of the finger over the surface of the joint that is to be fused. Special care is taken not to damage the nearby nerves going to the finger.

The joint capsule surrounding the finger joint is then opened so that the surgeon can see the joint surfaces. Both joint surfaces are prepared to inter lock with each other. The surgeon places a pin through the center of both bones.

The metal or biodegradable pin allows the doctor to hold the two bones in the correct alignment and prevents the bones from moving too much as they grow together or fuse. The skin and tissue that covers the joint is then sewn back together by the doctor. The forearm and hand are then placed in a cast until the bones completely fuse together. This takes about six weeks.

What to expect after surgery?

This is dependant on your doctor’s post surgical regime. If you have surgery, your hand will be bandaged with a well-padded dressing and a finger splint for support. Physical therapy sessions may be needed after surgery for up to eight weeks. The first few treatments are used to help control the pain and swelling after surgery.